Provider Demographics
NPI:1679710123
Name:WRIGHT, RUSSELL W (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:W
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7303
Mailing Address - Country:US
Mailing Address - Phone:208-433-9466
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:C/O BOISE RADIOLOGY GROUP
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN19612085R0202X
IDM-118922085R0202X
MA2502922085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging